due to
_________________________________________________________________________=
_____________________________________________

(REAS=
ON FOR
SEPARATION)

=

I =
fully
understand the benefits of leaving my accumulated contributions on deposi=
t in
the Genesee County Employees' Retirement System (GCERS) and realize that =
if I
were not to withdraw this accumulation I may be eligible for a deferred
retirement allowance upon written application to the Retirement Commissio=
n.

I =
also
fully understand that the reciprocity provision of the GCERS that if I ha=
ve at
least two and one-half (2 1/2) years of credited service and leave my
accumulated contributions on deposit in the GCERS and that should I be
employed by another public employer whose retirement system is also a
reciprocal retirement system, that I would be eligible for retirement
benefits from the GCERS.I
understand that should I withdraw my accumulated contributions from the G=
CERS
and later become employed with another public employer, I should immediat=
ely obtain
information concerning repayment of these refunded monies under reciproci=
ty
and any time limitations pursuant to the reciprocity provision.

I =
also
fully understand that if I am reemployed by an employer of the GCERS I ma=
y be
credited with the amount of membership service that I am forfeiting due to
this withdrawal of retirement contributions, subject to the following
conditions:

(1)Application is m=
ade
within twelve (12) months of reemployment.

(2)The membership s=
ervice
I was previously credited must have been service rendered for an employer
participant of this

=
Retirement System.

(3)I deposit in the
Genesee County Employees' Retirement System an amount equal to the aggreg=
ate
amount of contributions I made at the

=
time of the previous membership service plus interest compounded annually
from the date of withdrawal of the accumulated contributions

=
to the date of deposit, at rates determined by=
the
Retirement Commission.If r=
ecords
are insufficient or unavailable to compute the exact

=
amount of required deposit, the Retirement
Commission may estimate the amount.

(4)I deposit in the
Genesee County Employees' Retirement System an amount equal to the the aggregate amount of contributions the

=
employer participant made at the time of the previous membership service =
plus
interest compounded annually from the date of

=
separation to the date of=
deposit,
at rates determined by the Retirement Commission.

Kn=
owing
these facts, I still hereby apply for all the accumulated contributions a=
nd
if applicable any interest to this member.

By=
signing
this application, I am authorizing the Retirement Office to contact the
appropriate Personnel Department to confirm the last day of employment an=
d to
contact the appropriate Payroll Department to obtain current year to date
contributions and that I am forfeiting my pension rights.